FLUVOXAMINE (Luvox, Fevarin)
Back to   Side-Effects

• 0.0 OVERVIEW
• 0.1 LIFE SUPPORT
• A. This overview assumes that basic life support measures have been instituted.
• 0.2 CLINICAL EFFECTS
• 0.2.1 SUMMARY OF EXPOSURE
• A. More experience is needed to evaluate the toxicity of this agent. Cardiovascular abnormalities have not been remarkable. The primary effects seen have been coma, nausea, and liver enzyme elevations. Most of the ingestions were mixed with other drugs, so it has been difficult to separate fluvoxamine effects.
• B. Doses below 1000 milligrams generally produced symptoms of drowsiness, nausea or vomiting, abdominal pain, tremors, sinus bradycardia, and mild anticholinergic symptoms. Doses above this sometimes produced seizures and severe bradycardia.
• 0.2.4 HEENT
• A. Miosis has been reported after therapeutic administration.
• 0.2.5 CARDIOVASCULAR
• A. EKG changes have not been remarkable. There has been some mild bradycardia and orthostatic hypotension reported with therapeutic doses. One case showed mild hypertension, but antihistamines were also involved.
• B. Severe bradycardia was reported following a fluvoxamine overdose.
• 0.2.6 RESPIRATORY
• A. Respiratory support has been necessary in severe cases of coma.
• 0.2.7 NEUROLOGIC
• A. Coma has been reported in a few cases where benzodiazepines were also involved. Agitation and both visual and tactile hallucinations were noted in one case where antihistamines and benzodiazepenes were also involved.
• 0.2.8 GASTROINTESTINAL
• A. Nausea and vomiting is the most common side effect noted.
• 0.2.9 HEPATIC
• A. Elevated liver enzymes has been reported in both overdose and therapeutically.
• 0.2.20 REPRODUCTIVE
• A. At the time of this review, no data were available to assess the potential effects of exposure to this agent during pregnancy or lactation.
• B. At the time of this review, no data were available to assess the teratogenic potential of this agent.
• 0.3 LABORATORY/MONITORING
• A. Monitor liver enzymes in overdose.
• B. Therapeutic level for a 100 mg/day dose is 0.4 mg/L.
• 0.4 TREATMENT OVERVIEW
• 0.4.1 SUMMARY
• A. No specific antidote exists. Patients should have standard cardiovascular monitoring (pulse, blood pressure) as well as liver function monitoring. In overdose, vomiting has not been so severe as to warrant fluid and electrolyte replacement.
• 0.4.2 ORAL/PARENTERAL EXPOSURE
• A. EMESIS: Ipecac-induced emesis is not recommended because of the potential for CNS depression and seizures.
• B. GASTRIC LAVAGE: Consider after ingestion of a potentially life-threatening amount of poison if it can be performed soon after ingestion (generally within 1 hour). Protect airway by placement in Trendelenburg and left lateral decubitus position or by endotracheal intubation. Control any seizures first.
• 1. CONTRAINDICATIONS: Loss of airway protective reflexes or decreased level of consciousness in unintubated patients; following ingestion of corrosives; hydrocarbons (high aspiration potential); patients at risk of hemorrhage or gastrointestinal perforation; and trivial or non-toxic ingestion.
• C. ACTIVATED CHARCOAL: Administer charcoal as slurry (240 mL water/30 g charcoal). Usual dose: 25 to 100 g in adults/adolescents, 25 to 50 g in children (1 to 12 years), and 1 g/kg in infants less than 1 year old.
• D. SEIZURES: Administer a benzodiazepine IV; DIAZEPAM (ADULT: 5 to 10 mg, repeat every 10 to 15 min as needed. CHILD: 0.2 to 0.5 mg/kg, repeat every 5 min as needed) or LORAZEPAM (ADULT: 4 to 8 mg; CHILD: 0.05 to 0.1 mg/kg).
• 1. Consider phenobarbital if seizures recur after diazepam 30 mg (adults) or 10 mg (children > 5 years).
• 2. Monitor for hypotension, dysrhythmias, respiratory depression, and need for endotracheal intubation. Evaluate for hypoglycemia, electrolyte disturbances, hypoxia.
• 0.5 RANGE OF TOXICITY
• A. The therapeutic amount is 50 to 300 mg per day.
• B. Doses of up to 6.5 grams have been survived. Coma has been reported in overdoses of 1.5 and 3 grams.
• 1.0 SUBSTANCES INCLUDED/SYNONYMS
• 1.1 THERAPEUTIC/TOXIC CLASS
• A. Fluvoxamine is an antidepressant with potent, selective inhibitory activity on neuronal serotonin re-uptake. Fluvoxamine is not structurally related to the tricyclic antidepressants.
• B. Fluvoxamine is investigational in the United States, but a New Drug Application has been filed by Reid-Rowell.
• C. The onset to its therapeutic effect was as soon as 4 to 7 days in some cases (Feldman & Denber, 1982; Saletu et al, 1977; Wright & Denber, 1978) and as long as 1 to 2 weeks in others (Guy et al, 1984; Dick & Ferrero, 1983).
• 1.2 SPECIFIC SUBSTANCES

o             Fluvoxamine

o             DU 23000

o             MK 264

• 1.6 AVAILABLE FORMS/SOURCES
• A. Trade Names for fluvoxamine maleate:

§               Avoxin(R)

§               Dumirox(R)

§               Dumyrox(R)

§               Faverin(R)

§               Floxyfral(R) (United States)

• 3.0 CLINICAL EFFECTS
• 3.1 SUMMARY OF EXPOSURE
• A. More experience is needed to evaluate the toxicity of this agent. Cardiovascular abnormalities have not been remarkable. The primary effects seen have been coma, nausea, and liver enzyme elevations. Most of the ingestions were mixed with other drugs, so it has been difficult to separate fluvoxamine effects.
• B. Doses below 1000 milligrams generally produced symptoms of drowsiness, nausea or vomiting, abdominal pain, tremors, sinus bradycardia, and mild anticholinergic symptoms. Doses above this sometimes produced seizures and severe bradycardia.
• 3.3 VITAL SIGNS
• 3.3.3 TEMPERATURE
• A. Mild hyperpyrexia was seen in an adult who ingested 2500 mg of fluoxamine together with 6 capsules of brompheniramine and flurazepam (Crome & Ali, 1986).
• 3.4 HEENT
• 3.4.1 SUMMARY
• A. Miosis has been reported after therapeutic administration.
• 3.4.3 EYES
• A. MIOSIS has been noted in patients taking this agent therapeutically (Wilson et al, 1983).
• B. MYDRIASIS has been reported in overdose (Garnier et al, 1993).
• 3.5 CARDIOVASCULAR
• 3.5.1 SUMMARY
• A. EKG changes have not been remarkable. There has been some mild bradycardia and orthostatic hypotension reported with therapeutic doses. One case showed mild hypertension, but antihistamines were also involved.
• B. Severe bradycardia was reported following a fluvoxamine overdose.
• 3.5.2 CLINICAL EFFECTS
• A. HYPOTENSION
• 1. Orthostatic hypotension has been reported with therapeutic administration in obsessive compulsive patients. It improved later in individual therapy (Price et al, 1987).
• 2. Mild hypotnesion has been reported with overdose (Garnier et al, 1993).
• B. HYPERTENSION
• 1. CASE REPORT - Mild hypertension was seen in an adult who ingested 2500 mg of fluvoxamine together with 6 capsules of brompheniramine and flurazepam (Crome & Ali, 1986).
• C. ECG ABNORMAL
• 1. Electrocardiographic changes have been minor when given therapeutically (Robinson & Doogan, 1982).
• 2. CASE REPORTS - A 63-year-old who took 1,500 mg and a 74-year-old who took 3 grams both had normal electrocardiograms (Lam et al, 1988; Banerjee, 1988).
• 3. In a analysis of EKG data from several authors, fluvoxamine caused slight increases in the R-R, QT, and QTc intervals (Guelfi et al, 1983; Dewilde & Doogan, 1982; DeWilde et al, 1983; Benfield & Ward, 1986). T-wave configurations like those seen after tricyclic antidepressant administration were not seen (Roos, 1983).
• 4. CASE REPORT - A 32-year-old female developed QT segment lengthening, T wave alterations, and first degree right branch block after ingesting approximately 1500 mg fluvoxamine, 1600 mg pipamperone, and 50 mg lorazepam in an apparent suicide attempt. The ECG abnormalities resolved the following day (Gallerani et al, 1998).
• D. BRADYCARDIA
• 1. In a survey of 228 cases, sinus bradycardia was the most common sign of cardiac toxicity (Azoyan et al, 1990).
• 2. CASE REPORT - Langlois & Paquette (1994) report a case of a 59-year-old female who ingested 2 grams fluvoxamine, 200 mg buspirone and 300 mg flurazepam in a suicide attempt. Bradycardia was noted on admission to the ED with ECG readings showing sinus bradycardia which lasted nearly 8 days following the overdose. Blood pressure remained normal throughout her hospital stay.
• 3. Bradycardia not requiring treatment has been reported after ingestion of less than 1000 milligrams (Garnier et al, 1993).
• 4. CASE REPORT - A 58-year-old female developed severe sinus bradycardia and complained of severe fatigue several hours after ingesting 5.5 grams of fluvoxamine in an apparent suicide attempt. The patient recovered following supportive care (Amital et al, 1994).
• E. TACHYCARDIA
• 1. Sinus tachycardia has been reported (Garnier et al, 1993).
• 2. CASE REPORT - Tachycardia developed in an adult who ingested 2500 mg of fluvoxamine together with 6 capsules of brompheniramine and flurazepam (Crome & Ali, 1986).
• F. ARRHYTHMIA VENTRICULAR
• 1. PVCs not requiring therapy have been occasionally reported (Garnier et al, 1993).
• 3.5.3 ANIMAL EFFECTS
• A. ARRHYTHMIA
• 1. RABBITS - When studied in rabbits, arrhythmias were infrequently seen. EKG disturbances were seen only at doses nearing lethality (Wouthers & Deiman, 1983).
• 3.6 RESPIRATORY
• 3.6.1 SUMMARY
• A. Respiratory support has been necessary in severe cases of coma.
• 3.6.2 CLINICAL EFFECTS
• A. RESPIRATORY DEPRESSION
• 1. Respiratory depression may be seen in conjuction with coma. Cases where respiratory support was required also involved benzodiazepenes in the overdose (Banerjee, 1988, Lam et al, 1988).
• 3.7 NEUROLOGIC
• 3.7.1 SUMMARY
• A. Coma has been reported in a few cases where benzodiazepines were also involved. Agitation and both visual and tactile hallucinations were noted in one case where antihistamines and benzodiazepenes were also involved.
• 3.7.2 CLINICAL EFFECTS
• A. CNS DEPRESSION
• 1. CASE REPORT - Coma developed in a 74-year-old who ingested 3 grams in combination with 250 mg of temazepam (Banerjee, 1988).
• 2. CASE REPORT - Coma, necessitating respiratory assistance, was also noted in a 63-year-old who ingested 1,500 mg of fluvoxamine and 40 mg of flunitrazepam.
• 3. Mild drowsiness has also been reported after overdose (Garnier et al, 1993).
• 4. Somnolence was noted in 26% of patients taking this drug therapeutically (Benfield & Ward, 1986).
• 5. CASE REPORT - A 32-year-old female presented to the ED in a comatose state (Glascow Coma Scale of 7) 5 hours after ingesting 1500 mg fluvoxamine, 1600 mg pipamperone, and 50 mg lorazepam in an apparent suicide attempt. The patient recovered following gastric lavage and intravenous infusion of flumazenil (Gallerani et al, 1998).
• B. HEADACHE
• 1. Headache was noted in 22% of patients taking this drug therapeutically (Benfield & Ward, 1986).
• C. AGITATION
• 1. Agitation was noted in 16% of patients taking this drug therapeutically (Benfield & Ward, 1986). Agitation was seen in an adult who ingested 2500 mg of fluvoxamine together with 6 capsules of brompheniramine and flurazepam (Crome & Ali, 1986).
• D. SEIZURES
• 1. At least 13 cases of seizures have been reported during fluvoxamine therapy (Reynolds, 1990). In one series doses above 1000 milligrams sometimes produced seizures (Azoyan et al, 1990).
• E. HALLUCINATION
• 1. CASE REPORT - Both tactile and visual hallucinations were seen in an adult who ingested 2500 mg of fluoxamine together with 6 capsules of brompheniramine and flurazepam (Crome & Ali, 1986).
• F. DIZZINESS
• 1. CASE REPORT - Intense dizziness, mild psychomotor impairment, ataxia, and slowed but coherent speech developed in a 59-year-old female after intentional ingestion of 2000 mg fluvoxamine, 200 mg buspirone, and 300 mg flurazepam (Langlois et al, 1994).
• G. TREMOR
• 1. Tremor has been reported rarely after overdose (Garnier et al, 1993)
• 3.8 GASTROINTESTINAL
• 3.8.1 SUMMARY
• A. Nausea and vomiting is the most common side effect noted.
• 3.8.2 CLINICAL EFFECTS
• A. NAUSEA VOMITING
• 1. Nausea and vomiting are common early in fluvoxamine therapy; up to 37% of individuals experience this side effect (Benfield & Ward, 1986).
• B. MOUTH DRY
• 1. Dry mouth occurred in about 3.7 to 26% of patients who were on fluvoxamine therapy (Benfield & Ward, 1986; Martin et al, 1987) and has been reported after overdose (Garnier et al, 1993).
• C. CONSTIPATION
• 1. Constipation was reported in 18% of patients on therapy (Benfield & Ward, 1986).
• D. ANOREXIA
• 1. Anorexia developed in 15% of patients on therapy (Benfield & Ward, 1986).
• 3.9 HEPATIC
• 3.9.1 SUMMARY
• A. Elevated liver enzymes has been reported in both overdose and therapeutically.
• 3.9.2 CLINICAL EFFECTS
• A. HEPATIC ENZYMES INCREASED
• 1. CASE REPORT - Elevated ASAT, ALAT, GGT, and bilirubin were reported in a 63-year-old who ingested 1,500 mg (Lam et al, 1988).
• 2. Elevated aminotransferases developed in one patient out of 69 who ingested ovedoses of fluvoxamine alone (Garnier et al, 1993)
• 3. Reports of liver toxicity are rare therapeutically. One man reported a three fold increase in gamma glutamyl transferase over baseline and an enlarged liver after 3 weeks of fluvoxamine 100 mg twice daily (Green, 1988).
• 4. 15 of 228 cases in one study had elevated enzymes, however, a direct, causal relationship could not be proven (Azoyan et al, 1990).
• 3.16 ENDOCRINE
• 3.16.2 CLINICAL EFFECTS
• A. HYPOGLYCEMIA
• 1. Mild hypoglycemia developed in one of 69 patients with overdose of fluvoxamine alone (Garnier et al, 1993).
• 3.20 REPRODUCTIVE
• 3.20.1 SUMMARY
• A. At the time of this review, no data were available to assess the potential effects of exposure to this agent during pregnancy or lactation.
• B. At the time of this review, no data were available to assess the teratogenic potential of this agent.
• 3.20.2 TERATOGENICITY
• A. LACK OF INFORMATION
• 1. At the time of this review, no data were available to assess the teratogenic potential of this agent.
• 3.20.3 EFFECTS IN PREGNANCY
• A. LACK OF INFORMATION
• 1. At the time of this review, no data were available to assess the potential effects of exposure to this agent during pregnancy or lactation.
• 3.21 CARCINOGENICITY
• 3.21.3 HUMAN STUDIES
• A. LACK OF INFORMATION
• 1. At the time of this review, no data were available to assess the carcinogenic or mutagenic potential of this agent.
• 4.0 LABORATORY/MONITORING
• 4.1 MONITORING PARAMETERS/LEVELS
• 4.1.1 SUMMARY
• A. Monitor liver enzymes in overdose.
• B. Therapeutic level for a 100 mg/day dose is 0.4 mg/L.
• 4.1.2 SERUM/BLOOD
• A. BLOOD/SERUM CHEMISTRY
• 1. GAMMA GLUTAMYL TRANSFERASE - Increases of more than 3 fold over baseline were seen following 3 weeks of fluvoxamine 100 mg twice daily (Green, 1988). The levels dropped to near normal 5 weeks after stopping the therapy. Other liver enzymes have been elevated after overdose, and should be monitored (Lam et al, 1988).
• 2. SERUM MELATONIN - Increases were noted in healthy male volunteers who took 150 mg of fluvoxamine at night (Demisch et al, 1986).
• 4.3 METHODS
• A. CHROMATOGRAPHY
• 1. Fluvoxamine has been determined in plasma by the use of high performance liquid chromatography (DeJong, 1980) and electron capture gas chromatography (Hurst, 1981).
• 5.0 ABSTRACTS
• 5.1 CASE REPORTS
• A. ACUTE EFFECTS
• 1. ADULT
• a. A 74-year-old ingested 3 grams of fluvoxamine and 250 mg of temazepam. The patient was lavaged in the emergency department.
• (1) She was comatose, afebrile, with a heart rate of 70 beats per minute, a respiratory rate of 20, and a blood pressure of 80/50 mmHg. She had no gag reflex, and was unresponsive to pain.
• (2) The electrocardiogram was normal. She was treated with supportive measures and within 24 hours her blood pressure had returned to normal (110/70 mmHg) (Banerjee, 1988).
• (3) This woman remained comatose for 5 days and improved on the 6th. The temazepam level peaked at over 1.8 mg/L within a few hours of ingestion. The fluvoxamine level peaked on day three at over 1.4 mg/L (Banerjee, 1988).
• 5.2 CASE SERIES
• A. ACUTE EFFECTS
• 1. Garnier et al (1993) report results of a case series of 221 acute overdoses with fluvoxamine. In 77% of the cases other agents, primarily benzodiazepines, neuroleptics, other antidepressants and alcohol were also ingested. The acute toxicity that could be attributed to fluvoxamine alone was rarely severe.
• a. Symptoms observed at doses less than 1000 mg included drowsiness, tremor, nausea and vomiting, abdominal pain, bradycardia and/or anticholinergic effects (dry mouth, mydriasis, sinus tachycardia, urinary retention). Seizures occurred in a few cases after high doses (generally greater than 1500 mg). Cardiotoxicity was not a serious problem; sinus bradycardia was noted with doses less than 1000 mg, and was generally moderate and required no treatment. Conduction abnormalities were rare.
• 6.0 TREATMENT
• 6.1 LIFE SUPPORT
• A. Support respiratory and cardiovascular function.
• 6.2 TREATMENT SUMMARY
• A. No specific antidote exists. Patients should have standard cardiovascular monitoring (pulse, blood pressure) as well as liver function monitoring. In overdose, vomiting has not been so severe as to warrant fluid and electrolyte replacement.
• 6.4 MONITORING
• A. Monitor liver enzymes in overdose.
• B. Therapeutic level for a 100 mg/day dose is 0.4 mg/L.
• 6.5 ORAL EXPOSURE
• 6.5.1 PREVENTION OF ABSORPTION/PREHOSPITAL
• A. EMESIS/NOT RECOMMENDED -
• 1. EMESIS: Ipecac-induced emesis is not recommended because of the potential for CNS depression and seizures.
• B. ACTIVATED CHARCOAL -
• 1. PREHOSPITAL ACTIVATED CHARCOAL ADMINISTRATION
• a. Consider prehospital administration of activated charcoal as an aqueous slurry in patients with a potentially toxic ingestion who are awake and able to protect their airway. Activated charcoal is most effective when administered within one hour of ingestion.
• (1) In patients who are at risk for the abrupt onset of seizures or mental status depression, activated charcoal should be administered by medical or paramedical personnel capable of airway management to prevent aspiration in the event of spontaneous emesis.
• 2. CHARCOAL DOSE
• a. Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years; and 1 gram/kilogram in infants up to 1 year old (USP DI, 2000; Chyka & Seger, 1997).
• (1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (Barceloux et al, 1997).
• b. ADVERSE EFFECTS/CONTRAINDICATIONS
• (1) Complications: emesis, aspiration (Chyka & Seger, 1997). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
• (2) Contraindications: unprotected airway, gastrointestinal tract not anatomically intact, therapy may increase the risk or severity of aspiration; ingestion of most hydrocarbons (Chyka & Seger, 1997).
• 6.5.2 PREVENTION OF ABSORPTION
• A. GASTRIC LAVAGE
• 1. INDICATIONS: Consider gastric lavage with a large-bore orogastric tube (ADULT: 36 to 40 French or 30 English gauge tube {external diameter 12 to 13.3 mm}; CHILD: 24 to 28 French {diameter 7.8 to 9.3 mm}) after a potentially life threatening ingestion if it can be performed soon after ingestion (generally within 60 minutes).
• a. Consider lavage more than 60 minutes after ingestion of sustained-release formulations and substances known to form bezoars or concretions.
• 2. PRECAUTIONS:
• a. SEIZURE CONTROL: Is mandatory prior to gastric lavage.
• b. AIRWAY PROTECTION: Alert patients - place in Trendelenburg and left lateral decubitus position, with suction available. Obtunded or unconscious patients - cuffed endotracheal intubation.
• 3. LAVAGE FLUID:
• a. Use small aliquots of liquid. Lavage with 150 to 200 milliliters warm tap water (preferably 38 degrees Celsius) or saline per wash (in children over 5 or adults) and 10 milliliters/kilogram body weight of normal saline in young children. Continue until lavage return is clear.
• b. The volume of lavage return should approximate amount of fluid given to avoid fluid-electrolyte imbalance.
• c. CAUTION: Water should be avoided in young children because of the risk of electrolyte imbalance and water intoxication. Warm fluids avoid the risk of hypothermia in very young children and the elderly.
• 4. COMPLICATIONS:
• a. Complications of gastric lavage have included: aspiration pneumonia, hypoxia, hypercapnia, mechanical injury to the throat, esophagus, or stomach, fluid and electrolyte imbalance (Vale, 1997). Combative patients may be at greater risk for complications.
• b. Gastric lavage can cause significant morbidity; it should NOT be performed routinely in all poisoned patients (Vale, 1997).
• 5. CONTRAINDICATIONS:
• a. Loss of airway protective reflexes or decreased level of consciousness if patient is not intubated, following ingestion of corrosive substances, hydrocarbons (high aspiration potential), patients at risk of hemorrhage or gastrointestinal perforation, or trivial or non-toxic ingestion.
• B. ACTIVATED CHARCOAL
• 1. CHARCOAL ADMINISTRATION
• a. Consider administration of activated charcoal after a potentially toxic ingestion (Chyka & Seger, 1997). Administer charcoal as an aqueous slurry; most effective when administered within one hour of ingestion.
• 2. CHARCOAL DOSE
• a. Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years; and 1 gram/kilogram in infants up to 1 year old (USP DI, 2000; Chyka & Seger, 1997).
• (1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (Barceloux et al, 1997).
• b. ADVERSE EFFECTS/CONTRAINDICATIONS
• (1) Complications: emesis, aspiration (Chyka & Seger, 1997). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
• (2) Contraindications: unprotected airway, gastrointestinal tract not anatomically intact, therapy may increase the risk or severity of aspiration; ingestion of most hydrocarbons (Chyka & Seger, 1997).
• 6.5.3 TREATMENT
• A. SYMPTOMATIC/SUPPORTIVE CARE
• 1. No specific antidote exists, treatment is supportive.
• B. FLUID/ELECTROLYTES
• 1. Although vomiting has not been extensive in overdose to date, patients should be monitored for fluid and electrolyte loss, and appropriate replacement therapy instituted when necessary.
• C. SEIZURES
• 1. SUMMARY
• a. Attempt initial control with a benzodiazepine (diazepam or lorazepam). If seizures persist or recur administer phenobarbital. Benzodiazepines and barbiturates are generally preferred over phenytoin for the control of overdose or withdrawal related seizures.
• b. Monitor for respiratory depression, hypotension, dysrhythmias, and the need for endotracheal intubation.
• c. Evaluate for hypoxia, electrolyte disturbances, and hypoglycemia (or treat with intravenous dextrose ADULT: 50 milliliters IV, CHILD: 2 milliliters/kilogram 25% dextrose).
• 2. DIAZEPAM
• a. MAXIMUM RATE: Administer diazepam intravenously over 2 to 3 minutes (maximum rate = 5 milligrams/minute).
• b. ADULT DIAZEPAM DOSE: 5 to 10 milligrams initially, repeat every 5 to 10 minutes as needed. Monitor for hypotension, respiratory depression and the need for endotracheal intubation. Consider a second agent if seizures persist or recur after diazepam 30 milligrams.
• c. PEDIATRIC DIAZEPAM DOSE: 0.2 to 0.5 milligram per kilogram repeat every 5 minutes as needed. Monitor for hypotension, respiratory depression and the need for endotracheal intubation. Consider a second agent if seizures persist or recur after diazepam 10 milligrams in children over 5 years or 5 milligrams in children under 5 years of age.
• d. RECTAL USE: If an intravenous line cannot be established, diazepam may be given per rectum (generally use twice the usual initial dose because of decreased absorption), or lorazepam may be given intramuscularly.
• e. MIDAZOLAM: has been used intramuscularly and intranasally, particularly in children when intravenous access has not been established. PEDIATRIC MIDAZOLAM DOSE: INTRAMUSCULAR: 0.2 milligram/kilogram (maximum 7 milligrams) (Chamberlain et al, 1997); INTRANASAL: 0.2 milligram/kilogram (Lahat et al, 2000). Buccal midazolam, 10 milligrams, has been used in adolescents and older children (5-years-old or more) to control seizures when intravenous access was not established (Scott et al, 1999).